Hospital Pharmacist
Vol 9 No 3 p60
March 2002

For best results, use "a spoonful of sugar" regularly

By Keith Farrar, MRPharmS, MCPP

In the past decade, hospital pharmacists have not had much to smile about. A steadily increasing differential between community and hospital pharmacy staff pay, and the accumulation of student debts as a result of the need to take loans, has discouraged many young pharmacists from pursuing a career in hospital pharmacy. In addition, the creation of several primary care pharmaceutical adviser posts has lured away some of the best middle-grade hospital pharmacists.

Now, however, the tide is turning in favour of hospital pharmacy. The Royal Pharmaceutical Society (with the changes made to the Code of Ethics) and the Department of Health (with the introduction of controls assurance and the medicines management framework) started the move towards increased visibility for pharmacists and medicines management. Although these changes have not always been positively received by practitioners, it is clear that they are designed to support pharmacists in the development of services. The document "Pharmacy in the future — implementing the NHS Plan", also sets out some clear initiatives for pharmacy as a whole and hospital pharmacy in particular.

The latest development is the publication of the Audit Commission report, "A spoonful of sugar — medicines management in NHS hospitals".¹ This publication offers a great opportunity for hospital pharmacy. It is aimed at trust boards, and it encourages them to make the most of their pharmacy staff and identify the impact that pharmacy can have on the care of patients. The report states that pharmacy is a clinical profession, a point that cannot be emphasised strongly enough. For far too long, pharmacy has not received the necessary investment because it has been seen as a supply service rather than a clinical service. The Commission provides the necessary evidence to challenge this misconception and redress the imbalance.

The Commission places the responsibility with trust boards of providing adequate pharmacy resources to deliver clinical pharmacy services. Trust boards can also ensure that the importance of medicines management is recognised, by elevating the chief pharmacist to the status of a clinical director and by taking steps to identify and manage medication errors. Other recommendations, aimed at government agencies, include the establishment of a standard mechanism for medication error reporting and the use of information technology, particularly electronic prescribing and automated dispensing.

The real onus for executing the recommendations in this report, however, lies with chief pharmacists. Like any beneficial intervention, this report has to be used effectively if any gains are to be made. Trust boards will need to be made aware of its existence, government agencies may need lobbying to establish a priority for investment in automation, and the clinical role of pharmacists needs to be firmly established in the minds of local managers and leading clinicians. The evidence of beneficial outcomes from clinical pharmacy must be translated into robust activity in the care of patients within hospitals. This will help to convince more hospital pharmacy staff that the benefits identified in the report can be delivered to patients locally.

Clearly, there is a need for hospital pharmacists to identify what is important to their own organisations, so that they can translate the Commission's recommendations into real benefits for patients in their local hospitals.

One example of how this might work is the introduction of original pack dispensing. Many health systems are now looking at total expenditure across health economies to try to maximise the benefits obtained from the funds available. Most primary care organisations are anticipating increases in drug expenditure beyond available funding, and so any innovation that reduces overall drug expenditure, especially in primary care, would be welcome. The introduction of original pack dispensing in hospitals has been shown to achieve this. The details of this saving were included in the budget-setting guidance for primary care organisations in the past financial year.

Another major area for urgent action by chief pharmacists is medication errors. Medication errors affect a significant number of patients, with 5–17 per cent suffering adverse effects of drugs.² There are about 7,000 medication doses administered in the average district general hospital (DGH) each day.¹ A 5 per cent error rate means that there are about 350 medication administration errors per day in the average DGH. As 1 in 1,000 of these has a potentially fatal outcome, this means that on average, one patient is seriously harmed or killed every three days. This is in addition to the victims of prescribing errors.

There is a clear association between adverse drug events and increased length of stay, estimated at 2.4–4.6 days. Although the interpretation of these studies in a local context is difficult, it is clear that there are significant risks and costs associated with errors in the use of medicines. If an error keeps a patient in hospital for just one extra day, it means that if 11,000 errors are prevented in a year, it will release the equivalent of a 30-bed ward! It would appear that hospital pharmacists have hundreds of opportunities to do this each day.

These issues are of enormous significance and there is ample evidence that pharmacists can successfully intervene to reduce these risks.^3,4 Although success in reducing error may be limited by a lack of resources, it is clear from the Commission's report that the attitudes of chief pharmacists can sometimes constrain the potential contribution of hospital pharmacists. In addition to being innovative in the delivery of local services, it is important to identify some "quick wins" that can be built on so as to secure the "buy-in" of local managers to the principles outlined in the report. The case for investment can then be made. This will involve identifying the staffing profile required and setting out an incremental programme to achieve it.

The Audit Commission has given us both an opportunity and a challenge. We need to rise to the challenge!

Mr Farrar is chief pharmacist at Wirral Hospitals NHS Trust and chairman of the Royal Pharmaceutical Society's Hospital Pharmacists Group committee